Homes4WoundedHeroes - Combat Wounded Veteran Application (Z)

Step 1 of 10

Before proceeding to the application, you must meet all the requirements below.

Combat Wounded Status*

Must be a combat wounded veteran (Purple Heart recipient given priority) from any American conflict.

Discharge Status*

Must be honorably retired or separated from the military. (Those with compelling situations, whom are still active, but scheduled to retire, or separate, from the military within 90 days, may be considered)

Mortgage Status*

Must intend to use this home as your Primary Residence. (Priority will be given to applicants who do not currently have a mortgage. Applicants with mortgages may still be considered, on a case by case basis)

Please select NEXT below, to continue to the application.

How did you hear about us?*

Please describe how you heard about us

Branch of Service*

US Army

Air Force

Marine Corps

US Navy

US Coast Guard

Please select the branches of the United States military that you served in

Purple Heart Recipient*

Yes

No

Contact Information

Applicant Name*

FirstLast

Applicant Date of Birth*

Date Format: DD slash MM slash YYYY

Please use the format dd/mm/yyyy

Address*

Street AddressAddress Line 2CityStateZIP Code

Cell Phone*

Home Phone*

Email*

Family Information

Marital Status:*

Name of Spouse*

Spouse Date of Birth*

Date Format: MM slash DD slash YYYY

Please use the format dd/mm/yyyy

Spouse Primary Phone Number*

Email of Spouse*

List ALL individuals who will be living in the home (Including Yourself)

1

Name of #1

FirstLast

Relationship of #1*

Occupant Date of Birth #1*

Date Format: MM slash DD slash YYYY

Please use the format dd/mm/yyyy

Occupant Age #1*

Please enter a number from 0 to 100.

2

Name of #2

FirstLast

Relationship of #2

Occupant Date of Birth #2

Date Format: MM slash DD slash YYYY

Please use the format dd/mm/yyyy

Occupant Age #2

Please enter a number from 0 to 100.

3

Name of #3

FirstLast

Relationship of #3

Occupant Date of Birth #3

Date Format: MM slash DD slash YYYY

Please use the format dd/mm/yyyy

Occupant Age #3

Please enter a number from 0 to 100.

4

Name of #4

FirstLast

Relationship of #4

Occupant Date of Birth #4

Date Format: MM slash DD slash YYYY

Please use the format dd/mm/yyyy

Occupant Age #4

Please enter a number from 0 to 100.

5

Name of #5

FirstLast

Relationship of #5

Occupant Date of Birth #5

Date Format: MM slash DD slash YYYY

Please use the format dd/mm/yyyy

Occupant Age #5

Please enter a number from 0 to 100.

6

Name of #6

FirstLast

Relationship of #6

Occupant Date of Birth #6

Date Format: MM slash DD slash YYYY

Please use the format dd/mm/yyyy

Occupant Age #6

Please enter a number from 0 to 100.

Demographics

We ask that you complete the following questions which will help MWSF in pursuit of additional funding for its programs through grants and sponsorships. Your answers will not impact your application process. The data collected is protected in accordance with the Privacy Act (93-579). Unauthorized disclosure of this information constitutes a violation of the Privacy Act. You are not required to provide this information, but are encouraged to answer honestly, so that future applicants may continue to benefit from our programs.

Applicant's Gender*

Which race/ethnicity best describes you?*

What is the highest degree or level of school you have completed? If currently enrolled, highest degree received?*

Age when entered military?*

Number of military years served?*

Have you been diagnosed with PTSD?*

Have been diagnosed with a Traumatic Brain Injury (TBI)?*

In the last 12 months have you spent the night in a shelter, mission, church, abandon building, car, park, or street?*

Military Information

Please answer the following questions openly and honestly.
This is your opportunity to tell us about you, your family and your current situation. Read questions carefully; be certain you are answering it completely.

Are you active Duty?*

Yes

No

What is your Service Status?*

Active Duty

Reserve

National Guard

Honorable Discharge

Retired

Medically Retired

What is your expected or actual date of discharge?*

Date Format: MM slash DD slash YYYY

Rank/Paygrade*

Current or at Retirement

Military Occupation Code*

Your Military Awards*

Select all awards applicable to your service. Not all awards will be represented.

NONE LISTED

Medal of Honor

Army Distinguished Service Cross

Navy Cross

Air Force Cross

Coast Guard Cross

Silver Star

Distinguished Flying Cross

Bronze Star Medal with 'V' Device

Bronze Star Medal

Purple Heart

Commendation Medal with 'V' Device

Commendation Medal with 'C' Device

Commendation Medal

Achievement Medal with 'V' Device

Achievement Medal with 'C' Device

Achievement Medal

Combat Infantryman Badge

Combat Action Badge

Combat Medic Badge

Combat Action Ribbon

Combat Action Medal

Afghanistan Campaign Medal

Inherent Resolve Campaign Medal

Iraq Campaign Medal

Vietnam Service Medal

Global War on Terrorism Service Medal

Global War on Terrorism Expeditionary Medal

(*Please note, upon further consideration, supporting documentation for all listed tours, awards and decorations will require supporting documentation. A copy of your DD214 (or equivalent) will be required. False claims of valor will not be tolerated.)

Please provide a history of your military career, include tours, awards given or commendations received.*

Have you been issued a Disability Rating by the VA?*

Yes

No

If yes, what is your Disability Rating?

Please describe your combat related injuries, dates, how they occurred,.
(*Please note, upon further consideration, a copy of any combat related award will be required.)

(If you currently own a home, have a mortgage, or are in the process of going through or completed a foreclosure - please list who your mortgage is through, how much you have left on the loan and if you are current on your payments. If you are no longer in the home, please explain why)

Do you, or any individual who would be residing in the property you are applying for, have debt?*

When would be the first available date to move, if selected for the home you are applying for?*

Date Format: MM slash DD slash YYYY

Have you previously applied for one of our homes?*

Yes

No

Why are you applying for this particular home?*

Do you, or a member of your family, require special modifications in the home? (i.e. wheelchair access, grab bars, etc.) If Yes, please explain in space at the bottom.*

Yes

No

Special Modifications Needed in Home (Be Specific)*

Have you been awarded or received a home through another 501(C)(3) organization?*

Yes

No

Who did you receive it through and when did you receive it?*

Did you return this gift?*

Yes

No

If yes, please explain the situation.*

What support structure will you have available to you, if selected for the home you are applying for?*

What employment, educational or income opportunities will you have in this area?*

Do you have any pets? *If Yes, you will need to provide how many, breed, sex, weight and if they are current on their vaccinations. Is the animal a certified licensed service animals?*

Yes

No

Additional Pet Information*

Please list all animals breed, sex, weight, and if they are current on all vaccinations.

Criminal History

Have you, or a member of your family, been charged or convicted of a crime?*

Yes

No

*If Yes, are you or them currently on probation? Please explain in the field marked as Criminal History.

Criminal History*

Is there any pending issues that would restrict you from moving out of your current county or state?*

Yes

No

*If Yes, please explain below.

Issues that would restrict you from moving*

Military & Personal References

Please provide the name and phone number of 2 references that will be contacted: one Military & one Personal

Military Reference Name*

Military (Someone you served in combat with, preferably a Superior Officer or NCO)

Military Reference Phone Number*

Personal Reference Name*

Personal (Cannot be immediate family or person currently living with you, please indicate nature and length of relationship)

Personal Reference Phone Number*

Statement of Truth*

Providing false information can cause a review and change in applicant status and may affect your eligibility to participate in any MWSF program.

By submitting the application, you confirm that you all the information contained in it, is truthful to the best of your knowledge. And that you give Military Warriors Support Foundation permission to contact you regarding our programs.